Week 9

9A: Accessory Digestive Organs

Accessory digestive organs

- Aid in chemical breakdown of food through secretions and enzymatic contributions
through processes that occur in small intestine
- Liver
 Process nutrients, secretes bile (fat emulsifier)
 Hepatic portal system
- Gall bladder
 Concentrates and stores bile
- Pancreas
 Secretes essential digestive enzymes

Liver
- Largest internal organ
- Heaviest gland of body
- Inferior to diaphragm and sits almost entirely within rib cage
- 2 major lobes – larger right and smaller left lobe
- Highly vascular
- 2 supporting ligaments
 Falciform ligament (mesenteric fold that extends from the under surface of the
diaphragm and goes between the two principal lobes of the liver and up to the
superior surface of the liver, and it helps to suspend the liver within the abdominal
cavity)
 separates 2 lobes
 ligamentum teres (round ligament)
 fibrous chord
 remanent of the umbilical vein of the fetus and it extends from the liver to the
umbilicus
- also, a quadrate and caudate lobe
- receives oxygenated blood via hepatic artery and nutrient rich deoxygenated blood from
hepatic portal vein
Functions of liver
- production and secretion of bile
 bile produced by hepatocytes, stored in the gallbladder
- liver cells = hepatocytes
 can secrete up to 1L of bile/per day – fat emulsifier
- also maintains blood glucose level – carb metabolism
 liver can breakdown glycogen
- stores fat soluble vitamins (A, D, E and K, as well as minerals iron and copper)
- removes toxic substances (drugs, alcohol) or secrete drugs into bile such as penicillin
- can also inactivate hormones, like thyroid hormones, estrogens and aldosterone

hepatic portal system

- the unique way that blood flows through the digestive system to pick up nutrients from
the stomach and the intestines and deliver them to the liver for processing and storage
- the liver receives blood from two sources
 from hepatic artery – obtains oxygenated blood
 from hepatic portal vein - receives deoxygenated blood, which contains newly
absorbed nutrients, drugs and possibly microbes and toxins from the gastrointestinal
tract
 - Branches of both hepatic artery and the hepatic portal vein will carry that blood into the
hepatic sinusoids (cells within the liver)
 this is where oxygen and most of the nutrients and then certain toxic substances are
taken up by the hepatocytes
 products manufactured by these hepatocytes, nutrients needed by other cells, are
then secreted back into the blood
- This then drains into the central vein, and eventually passes into hepatic vein and the
inferior vena cava back to the right atrium of the heart
- hepatic portal system is a way of taking the nutrients, toxic substances, waste materials
from the GI tract, taking it through the liver for cleansing, and then taking that blood
back to the heart for oxygenation

Liver structure and histology

- portal triad
 hepatic portal vein, hepatic artery and bile duct at periphery
- 3 different cell types in liver
 Hepatocytes – produce bile
 Bile canaliculi (bile duct system)
 Hepatic sinusoids – where oxygen and most of the nutrients and then certain toxic
substances are taken up by the hepatocytes
- Cells can be organized into anatomical and functional units in three different ways
 Hepatic lobule – described to be the functional unit of the liver
 Portal lobule
 Hepatic acinus
- for years anatomists described the hepatic lobule as the functional unit of the liver. And
according to this model, each hepatic lobule is shaped like a hexagon. And at its center
is the central vein radiating out from it are rows of hepatocytes and hepatic sinusoids
- located at three corners of the hexagon – a portal triad
- this model based on description of liver from adult pigs – hard to find this well-defined
hepatic lobule in humans
- hepatic plate – a section of each lobule
 1-2 hepatocyte cells thick
 Separated by capillary spaces (sinusoids)
- Present in the hepatic sinusoids are a modified macrophages (stellate reticulum
endothelial cells or Kupfer cells)
 destroy worn out white and red blood cells, as well as bacteria and other foreign
matter in the venous blood draining from the gastrointestinal tract
- hepatic portal triad, which takes blood from the stomach and the intestines, brings it to
the liver for cleansing. These stellate reticular endothelial cells will help cleanse some of
that blood as it's draining through the sinusoids to get to the central vein
Gallbladder
- pear-shaped sac
- inferior surface of liver
- stores/concentrates bile produced by liver – until needed in duodenum of small
intestine
- 3 parts
 Fundus – projects down beyond inferior border of liver
 Body – central portion, projects superiorly
 Neck – projects superiorly
Flow chart
- bile is produced by the liver, and then enters the right and left hepatic ducts
- From the right and left hepatic ducts, the bile flows into the common hepatic duct, and
then the common bile duct, eventually to the duodenum of the small intestine, through
a hepatopancreatic ampulla
- between meals bile flows into the gallbladder for storage because the sphincter of the
hepatopancreatic ampulla actually closes off the entrance to the duodenum when it's
not needed
- after a meal, there are several neural and hormonal stimuli that promote the production
and release of bile
 fatty acids and amino acids, and proteins, in the chyme, will enter the duodenum
and stimulate some of the duodenal endocrine cells to secrete the hormone
cholecytokinin (CCK) into the blood
 CCK causes contraction of the walls of the gallbladder, which squeezes the
stored bile out into the cystic duct, and then through the common bile duct
 CCK is really important in this process of the bile release from the gallbladder, it
also causes the relaxation of the sphincter of the hepatopancreatic ampulla,
which allows the bile to flow into the duodenum
- this whole process is enzymatically regulated, taking the bile from the liver and the
gallbladder as well as the pancreas and then taking it into the small intestine in the
duodenum for processing

Clinical connection: gallstones

- Insufficient bile salts or excessive cholesterol - may crystallize to form a gallstone
- as they grow in size and number, gallstones can cause minimal or intermittent and
actually complete obstruction to the flow of bile from the gallbladder into the
duodenum
- can get blockage
 In the neck or cystic duct
 Within gallbladder
 In the common bile duct
 - In about 10%, some form of complication
- Symptoms:
 Sudden, severe pain in upper abdomen
 Inflammation without an infection
- Acute treatment: drugs and shockwave to reduce size
- Chronic: gallbladder removal and contents may be needed for those with a history of
gallstones

Pancreas
- Retroperitoneal gland, posterior to the greater curvature of stomach
- Head, body and tail
- Usually connected to the duodenum by 2 ducts
- Made up of small clusters of glandular epithelial cells, about 99% of which are arranged
in clusters called acini – make up exocrine portion
 the cells within these acini secrete a mixture of fluid and digestive enzymes called
pancreatic juice
- the remaining 1% of the cells are organized into clusters called pancreatic islets- the
endocrine portion of the pancreas
 these cells secrete the hormones glucagon, insulin, somatostatin and pancreatic
polypeptide
Pancreas Structure
- the head is the expanded portion of the organ and this is right near the curve of the
duodenum
- projecting from the lower portion of the head is uncinate process that arches behind
the superior mesenteric artery
- superior to and to the left of the head are the central body and tapering tail
- Pancreatic secretions from the secreting cells into these little small ducts that ultimately
unite to form two larger ducts, which bring the secretions into the duodenum of the
small intestine
- the larger of the two ducts is the pancreatic duct
 in most people, the pancreatic duct joins the common bile duct from the liver and
the gallbladder and enters the duodenum as a common duct called the
hepatopancreatic ampulla
- The second and smaller of the two ducts is the accessory duct
 leads from the pancreas and then empties into the duodenum, about 2.5cm above
the hepatopancreatic ampulla

Pancreatic regulation
- the pancreas secretion is largely controlled by the hormones secretin and
cholecystokinin (CCK) -- released by the small intestine
- CCK
 Released in response to proteins and fat
 targets acini cells (exocrine cells of the pancreas) to release enzyme rich pancreatic
juice
- secretin
 released in response to HCl from the stomach, and stimulates the production of
bicarbonate rich pancreatic juice
- the CCK targets the acini cells of the pancreas to release the pancreatic juice, whereas
secretin then stimulates the production of the pancreatic juice within the small intestine
- PANCREATIC JUICE: clear, colorless liquid consisting mostly of water, some salts, sodium
bicarbonate, and several enzymes
 slightly alkaline pH
 buffers acidic gastric juice in chyme, stops the action of pepsin from the stomach,
and creates the proper pH for the action of digestive enzymes in the small intestine
 the sole purpose of pancreas

blood supply
- gallbladder
 supplied by branches of the hepatic artery
- pancreas
 supplied by the splenic artery to the body and the tail
 the superior mesenteric artery supplies the head and the neck
9B – ABDOMINAL QUADRANTS

Abdominal quadrants
- the abdominal quadrants are split by two planes
 the trans umbilical plane, which goes through the umbilicus
 At the level of L3 and L4 vertebrae, we also have the median plane, which runs
longitudinal through the body generating left and right halves
 this is how we get our right and left quadrants, right and left upper as well as right
and left lower
- make it easier to narrow down the areas of patient concern
Structures by quadrant – right upper quadrant
- Liver (right lobe)
- Gall bladder (under left lobe of liver)
- Duodenum
- Pancreas (head) 0 hooks into curve of duodenum
- Right kidney
- Right adrenal gland
- Hepatic flexure (right turn in large intestine)
- Transverse colon (right half)

Structures by quadrant – left upper quadrant

- Liver (left lobe)
- Pancreas (body, tail)
- Left kidney
- Left adrenal gland
- Splenic flexure
- Transverse colon (left half)
- Stomach (most)

Structures by quadrant – right lower quadrant

- Cecum
- Appendix
- Ileum
- Ascending colon (most)
- Right ovary
- Right uterine tube
- Right ureter

Structures by quadrant – left lower quadrant

- Sigmoid colon
 - Jejunum
- Descending colon (most)
- Left ovary
- Left uterine tube
- Left ureter

Aging and the digestive system

- overall – things slow down generally
 Decreased secretions
 Decreased motility of digestive organs
 Loss of strength and muscle tone
 Diminished response to pain and internal sensations
- upper GI tract
 reduced sensitivity to mouth irritations/sores
 loss of taste
 periodontal disease
 difficulty swallowing
 peptic ulcer disease
- small intestine
 duodenal ulcers
 appendicitis
 malabsorption
 maldigestion
- large intestine
 constipation
 hemorrhoids
 diverticular disease
- gallbladder issues
- Jaundice and cirrhosis (liver), pancreatitis
- Colon and rectal cancer, bowel obstruction and impactions